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THE KNEE IN PRIMARY CARE

THE KNEE IN PRIMARY CARE. Briant W.Smith, MD Orthopedic Surgery TPMG, Santa Rosa. Knee Pain. 48 yo patient with “the list”: “ My knee hurts but……” So does my back and I’ve been waking up a lot to urinate and My daughter says that I’m depressed and

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THE KNEE IN PRIMARY CARE

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  1. THE KNEE IN PRIMARY CARE Briant W.Smith, MD Orthopedic Surgery TPMG, Santa Rosa

  2. Knee Pain • 48 yo patient with “the list”: • “My knee hurts • but……” • So does my back and • I’ve been waking up a lot to urinate and • My daughter says that I’m depressed and • Would you look at this odd looking mole and • I need these disability forms filled out……

  3. Strategies • 1. Know the different presentations • 2. Know the age-specific diagnoses • 3. ‘Point to the Pain’ • 4. Use the examination to confirm the diagnosis.

  4. What’s on the Surface?

  5. What’s Inside?

  6. Patella • Biggest sesamoid in the body • Thickest cartilage in the body • Biggest contact stresses of any joint • Provides fulcrum for the quadriceps • Important in any bent-knee activity • Can dislocate, subluxate, malalign, degenerate, and just plain hurt.

  7. Patella

  8. What’s Inside?

  9. Ligaments • Two live on the outside (collaterals: MCL/LCL) and two on the inside (cruciates: ACL/PCL). • Provide stability to the knee.

  10. Collaterals MCL LCL

  11. Cruciates

  12. Cartilage • Starts out nice and smooth • Then can get ‘sick’: fissures/cracks/flakes (chondromalacia) • Can continue to progress to arthritis.

  13. What does the knee do? • Keeps us upright • Allows us to walk, run, jump • Gets us up and down stairs, hills, chairs.

  14. What aggravates the knee? • Standing • Walking/Running • Twisting • Stairs/Hills/Sitting • Squatting • Gym exercises • Everything

  15. How useful are the symptoms: • Swelling? • Locking? • Giving out?

  16. Symptoms vs Signs • Swelling is something the patient reports. Effusion is something you palpate • Locking is usually a temporary sensation whereas true locking is a block to extension and usually flexion < 90 degrees • Giving out is a reflex of the quadriceps muscle letting go due to pain.

  17. Knee Pain Imaging • If arthritis is on your list or you are going to refer a patient, order: • Standing AP both knees, both laterals and Merchant/Sunrise view radiographs.

  18. Knee Radiographs

  19. Knee MRI • 90-95% sensitive and specific • Useful to confirm diagnoses • But most diagnoses can be made with an average history and careful examination • Let the musculoskeletal specialist decide if it is necessary (orthopedist, physiatrist, OccHealth, rheumatologist)

  20. Strategies • 1. Know the different presentations • 2. Know the age-specific diagnoses • 3. ‘Point to the Pain’ • 4. Use the examination to confirm the diagnosis.

  21. Strategy #1 • How Do Patients Present?

  22. Presentations • 1. Atraumatic Swollen Knee • 2. Routine Office Visit • 3. Acute Injury “Blow-out”

  23. Atraumatic Swollen Knee • No Injury, Positive Effusion • Want to rule out: • Infection (hematogenous/post-op/post-inj) • Inflammation (RA, psoriasis, etc) • Reactive (meniscus, DJD) • ASPIRATE!!!

  24. Atraumatic Swollen Knee • Coronal plane needle angle. • Level of superior pole of patella.

  25. Atraumatic Swollen Knee • Joint Fluid: Send for: cell count and differential, crystals, culture and gram stain. • purple and red top tubes, culturettes. • Microbiology and Special forms (aerobe/anaerobe/fungal/TB). • Blood tests: CBC with diff, ESR, CRP. • Radiographs: AP/Lat/Merchant

  26. Atraumatic Swollen Knee • Situation Specific: • Lyme titer • PPD • Echo for a murmur • RF/ANA • Rashes/mouth ulcers/back symptoms, eye symptoms • MRI and/or bone scan • (or leave it to the rheumatologist)

  27. Atraumatic Swollen Knee Dx Cell count Culture ESR • Reactive 0-20K (-) <30 • Inflamm 20-50K (-) <50 • Infection >50K + >100 • joint 60% • blood 30%

  28. Knee PainPresentations • 1. Atraumatic Swollen Knee • 2. Routine Office Visit • 3. Acute Injury “Blow-out”

  29. Strategy #2The Routine Office Visit • Know the Age-Specific Diagnoses • Practical • Narrows the possibilities • Small list heavily weighted towards favorites

  30. Causes of Knee Pain 1. Meniscus 10. PVNS 19. Osgood-Schlatters 2. Ligament 11. Tumor 20. Tendon rupture 3. Plica 12. AVN 21. Chondromalacia 4. DJD 13. Referred 22. Bursitis 5. RA 14. Vascular 23. Loose body 6. Synovitis 15. Radicular 24. Deformity 7. Infection 16. Bruise 25. Dislocation 8. Patellar 17. Sprain 26. Fracture 9. OCD 18. Tendinitis 27. Neuroma

  31. Routine Office Visit • Teen patient (<20 yrs) • Patellofemoral syndrome (PFS) 95% • Tendinitis (patellar) • Osgood-Schlatters • Osteochondritis Dissecans (OCD) • Adult patient (20-48 yrs) • PFS • Meniscus tear • Ligament tear • Bursitis (prepatellar) • Tendinitis (IT band friction) • Older patient (>48 yrs) • Meniscus tear • Arthritis • Bursitis (pes)

  32. Strategy #3‘Point to the Pain’ Strategy #4 And use the examination to add supporting data to cinch the diagnosis.

  33. ‘Point to the Pain’

  34. ‘Point to the Pain’ • Combined with the history this gives you some idea of the diagnosis. • Anterior: PFS, Tendinitis, Osgood-Schlatters, • Bursitis • Medial:Meniscus, DJD, Bursitis • Lateral: Meniscus, DJD, Tendinitis • Posterior: Baker’ cyst, Vascular, Sciatica

  35. Example 1 • 16 yo girl with knee pain for one month • Makes a broad swath of pain around the front of the knee • Hurts to walk and go up stairs • Gives out

  36. Based on age: PFS History and aggravators sound patellar. Patellar signs: • Pain with single leg dip • Atrophy (rare) or tightness of quadriceps • NO effusion, jt line tenderness, instability

  37. Single Leg Knee Dip

  38. Quadriceps Tightnessand Stretch

  39. Patellofemoral SyndromeInitial treatment • “You don’t have anything serious. This almost always gets better with activity changes and stretching.” • No or limited bent-knee activity. Keep knee almost straight if sitting. Avoid stairs. • Straight leg raises to prevent atrophy. • Quadriceps stretching twice/day, 1 minute. • PT: taping/bracing/strengthening. • Might take 3 months to improve.

  40. PFS and Pain • Where does it come from? • Could be subchondral pressure • Could be surrounding synovial tissue • Could be ???

  41. Patellofemoral Malalignment or Subluxation • Special group. H/o ‘events’. • Kneecap sits or tracks laterally • High Q (quadriceps) angle, ‘J’ sign • +apprehension test • Might be tight laterally • Merchant XR might show tilting. • PT: taping/stretching/strengthening/sleeve

  42. Q Angle

  43. Knee PainNormal Exam • Occasionally the history isn’t helpful and the examination is normal. • Pick the DX that is most likely and if there is a failure to DX it will cause no harm: • PFS

  44. PFS and Failure to Improve • “Did you do what we talked about at the last visit? And that was...?” • If PT was ordered, did they go? • Consider a new XR, especially ‘tunnel’ view. • Re-examine the knee. Sometimes the exam is different. • Clearly PFS, continue PT. Consider referral. • Jt line tenderness or effusion: refer.

  45. Routine Office Visit • Teen patient (<20 yrs) • Patellofemoral syndrome (PFS) • Tendinitis • Osgood-Schlatters • OCD • Adult patient (20-48 yrs) • PFS • Meniscus tear • Ligament tear • Bursitis (patellar) • Tendinits (ITB) • Older patient (>48 yrs) • Meniscus tear • Arthritis • Bursitis (pes)

  46. Infrapatellar painTeen patient • Young patient, +/- history of overuse • Point tenderness at inferior pole of patella • “Jumper’s knee” = tendinitis • RICE, stop activity Sports when there is full, pain-free motion.

  47. Osgood-Schlatters Disease • Tibial tubercle (apophysis) becomes inflamed from repeated traction. • Prominent swelling • Tender at tubercle • XR: irregular lateral • Self-limited Sports when there is full, pain-free motion.

  48. Osteochondritis Dissecans (OCD)Teen patient • Localized avascular necrosis usually of the lateral wall of the medial femoral condyle. Locking Swelling Pain • Treat with RICE, refer for no improvement.

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